Splenic Injury in Children: Clinical Guidelines

List of Abbreviations

BP – Blood pressure

ICU – Intensive Care Unit, Anesthesiology and Reanimation

CT – Computed Tomography

BV – Blood Volume

Ultrasound – Ultrasound Investigation

Terms and Definitions

Asplenia – complete removal of splenic tissue

Hemoperitoneum – accumulation of blood in the peritoneal cavity

Isolated trauma – occurrence of an isolated traumatic injury in a single anatomical region (segment)

Omentosplenorrhaphy – suturing of the spleen using the greater omentum

Polytrauma – severe trauma with mutually aggravating syndrome and development of traumatic disease

Post-splenectomy hyposplenism – pathological condition caused by complete asplenia

Associated trauma – occurrence of two or more traumatic foci (isolated or multiple) in different anatomical regions (segments)

Splenectomy – surgical removal of the spleen

Trauma – disruption of the integrity and functions of organ tissue resulting from an external impact

Splenic fragmentation – rupture of the organ into parts

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Splenic injury – disruption of the integrity and functions of splenic tissues resulting from an external impact [1].

Closed splenic injury is a mechanical trauma to the organ not accompanied by a breach in the integrity of the external integument of the body [1].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Closed splenic injuries in children occur as a result of external force applied to the anterior abdominal wall and the lower half of the chest cavity. The impact of external force on the organ can be short-term or prolonged, resulting from collapses when the organ is compressed between the walls of the abdominal cavity. The degree of organ damage depends on the force of the impact, duration of exposure, state of the abdominal press, and its functional state. In severe transport accidents, when the impact or inertial force is significant, splenic injuries are often associated with other traumas. The most frequent type of injury in pedestrian children is being struck by a vehicle, involving multiple impacts from the bumper, hood, and windshield. At the moment of impact, the kinetic energy of the vehicle is transferred to the victim at its initial speed, causing additional injury from hitting the road surface. Injury to a child as a passenger can occur directly from a direct blow to the abdomen by parts of the vehicle during a direct collision with various objects, or due to inertia during abrupt braking. Any vehicle collision is accompanied by a sudden change in its speed, which is directly transmitted to the passenger secured by seat belts. In falls from a height, the mechanism of splenic injury is associated with inertia or counter-coup forces. At the moment the child's body hits the ground, the organ continues to move by inertia in the direction of the fall [2,3]. The anatomical characteristics of the child are also significant: due to the large volume of internal organs, the abdomen in children is protuberant and soft. The development of the abdominal and chest wall musculature takes time, so the abdominal and pelvic regions remain poorly protected in the event of trauma. The small muscle mass of a child has a low capacity to absorb the energy of external impact. Bones and ribs are more compliant and elastic, failing to provide adequate protection for internal organs [2]. Organ ruptures occur in a transverse direction due to the segmental arrangement of intra-organ vessels. Since the segmental branches of the splenic artery enter the organ independently, the separated fragments remain viable. Because the parenchymal tear lies between two uninjured segmental vessels, bleeding stops spontaneously [4].

1.3 Epidemiology of the Disease or Condition

In the structure of abdominal organ injuries in children, splenic injury ranks first, accounting for 48% to 77% [5,6,7]. Among the mechanisms of closed splenic injury, motor vehicle accidents predominate (23–25%), followed by falls from a height (10–23%) and blows to the abdomen (20%) [2,6,8].

1.4 Features of Coding the Disease or Condition

S36.0 – Injury of spleen

1.5 Classification of the disease or condition

Classification proposed by A.G. Pugachev and E.I. Finkelson (1981) [2]:

Grade I:

I a – organ contusion (single or multiple hemorrhages in the capsule and parenchyma, subcapsular hematomas, hemorrhages in the region of the organ hilum);

I b – isolated capsular ruptures (single or multiple);

Grade II: capsular and parenchymal ruptures (single or multiple);

Grade III: organ fragmentation (rupture into parts, avulsion of poles or individual sections of the organ, avulsion of the organ from the vascular pedicle);

Grade IV: organ maceration / shattering.

In accordance with the presented classification, the most frequent class of splenic injury in children was single or multiple capsular and parenchymal ruptures, or grades 1 and 2 (57.3%) [2].

In 1988, W.L. Buntain proposed a classification of splenic injuries in children based on computed tomography data [3]:

Classification of splenic injuries in children (Buntain W.L., 1988).

A strong positive correlation was revealed between the proposed classification and the Injury Severity Score (ISS). The classification accuracy was 97%, specificity 100%, and sensitivity 93%. Data obtained during surgery were used as the reference method [3].

Currently, the universally accepted classification of splenic injuries is the one adopted by the American Association for the Surgery of Trauma (AAST, 1991) [9].

AAST Splenic Injury Scale (Moore F.A. et al., 1991) [9]

Type of Injury	Class	Regimen	Description of Injury
Hematoma Laceration	I		Subcapsular, non-expanding, < 10% of surface area Capsular tear, non-bleeding, < 1 cm in depth
Hematoma Laceration	II		Subcapsular, non-expanding, 10–50% of surface area Intraparenchymal, non-expanding, < 2 cm in diameter Capsular tear, active bleeding, 1–3 cm in depth, without involvement of trabecular vessels
Hematoma Laceration	III		Subcapsular, > 50% of surface area or expanding Intraparenchymal, > 2 cm in diameter or expanding Rupture of subcapsular hematoma with active bleeding
Hematoma Laceration	IV		Laceration > 3 cm in depth or involving trabecular vessels Rupture of intraparenchymal hematoma with active bleeding
Laceration Vascular injury	V		Laceration involving segmental or hilar vessels, producing major devascularization (> 25%) Shattered spleen Hilar vascular injury with devascularization of the spleen

The World Society of Emergency Surgery (WSES) proposed a classification of splenic injuries in accordance with the AAST classification and the patient's hemodynamic status [10]. Four classes of splenic injuries are distinguished:

Minor injuries:

- Class I includes hemodynamically stable patients with injuries corresponding to AAST grades 1–2.

Moderate injuries:

- Class II includes hemodynamically stable patients with injuries corresponding to AAST grade 3, and penetrating injuries;

- Class III includes hemodynamically stable patients with AAST grades 4–5 splenic injuries and penetrating injuries.

Severe injuries:

- Class IV includes hemodynamically unstable patients with AAST grades 1–5 splenic injuries and penetrating injuries.

Literature data indicate that transcapsular transverse splenic ruptures in children occur most frequently, accounting for 54% to 80% [2,6,8]. Rare types of splenic injuries in children include: longitudinal rupture (1%), avulsion from the vascular pedicle (0.9%), contusion (3.9%), fragmentation (9.4%), and two-stage or delayed ruptures (0.9%) [2,6,8]. Minor splenic injuries are typical for children: in more than 80% of children, the area of pathological traumatic changes calculated on CT scans is 30%. Extensive injuries with an area of 50% or more occur in only 2.4% of children [2,6].

1.6 Clinical presentation of the disease or condition

In splenic trauma, the child's condition can be severe, and the degree of severity will depend on the class of organ injury and the volume of blood loss. In most cases, patients are admitted to the clinic in a severe condition with signs of shock and symptoms of blood loss. When examining the patient, it is necessary to pay attention to their posture and the presence of bruising in the left flank. Objective evidence of splenic injury is a forced posture – lying on the left side with thighs drawn up to the abdomen. Pain increases with changes in the patient's body position. The patient tends to return to the previous position (B.S. Rozanov's sign / "tumbler doll" sign). This reaction is observed when trying to lay a sitting child down. The sign is explained by the visceral component of pain due to irritation of the diaphragmatic peritoneum. Bruising in the left flank (Grey Turner's sign) or around the umbilicus due to blood infiltration of the abdominal wall tissues (Cullen's sign) may be present.

Important information can be obtained through palpation and percussion of the abdomen. Pain localized in the left upper quadrant radiating to the left half of the chest or the left shoulder is Kehr's sign, which is observed in 15–75% of cases. Abdominal distension (Heineke-Lejars sign) may be noted, which is pathogenetically associated with the dilation of intestinal loops in response to their irritation. Muscle guarding of the anterior abdominal wall is predominantly local in nature and is detected in the left hypochondrium. Tenderness upon abdominal palpation is determined in the majority of patients. Percussion reveals an accumulation of blood in the lateral gutters of the abdominal cavity. One of the signs of free blood is the shifting of percussion dullness in the lateral gutters when the patient's body position changes (Pitts-Beランス-Tomayer sign / Pitts-Ballance-Tomayer sign).

2. Diagnostics, medical indications and contraindications for diagnostic methods

2.1 Complaints and Anamnesis

• All patients should be asked during the history-taking about the circumstances and mechanism of injury, paying special attention to the force of the external impact [2,3].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• All patients should have the nature of their abdominal pain clarified during history-taking, as well as the presence of nausea and vomiting [2,3].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Commentary. Patients typically complain of generalized abdominal pain. The visceral component of the pain is largely determined by irritation of the diaphragmatic peritoneum, which accounts for the radiation of pain to the left hemithorax and the left shoulder. Particularly pronounced pain impulses are observed when the child changes position. Complaints of nausea and vomiting are possible.

2.2 Physical Examination

Commentary. In splenic trauma, the patient's condition can be severe, and the degree of severity will depend on the class of organ injury and the volume of blood loss.

Commentary. Pulse rate and blood pressure values are important hemodynamic parameters. Normal systolic blood pressure in children depending on age can be calculated using the formula: 90 mmHg + age (in years) × 2 [10].

Physiological blood pressure values in children of various ages (Pediatric Cardiology. 3rd ed. Philadelphia, 1972) [3].

Age-related pulse rate values are presented in the table

Age-related pulse rate values (Nelson W.B. Textbook of Pediatrics. 14th ed. Philadelphia, 1992) [3]

Commentary. The shock index is defined as the ratio of the pulse rate to the systolic blood pressure. The value of the shock index depends on the child's age: > 1.22 for children aged 4–6 years, > 1 for 6–12 years, > 0.9 for 13 years and older. An elevated shock index correlates with injury severity, the need for blood transfusion within the first 24 hours after injury, a longer stay in the intensive care unit, and a more severe grade of splenic injury [11,12].

Commentary. Objective evidence of splenic injury is a forced posture – lying on the left side with hips flexed toward the abdomen. Visceral pain impulses increase when the victim changes body position, and they attempt to return to the previous position (B.S. Rozanov's sign, « tumbler » sign). This reaction is observed when trying to lay a sitting child down. The sign is explained by the visceral component of pain due to irritation of the diaphragmatic peritoneum. Bruising may be present in the left flank (Grey Turner's sign) or around the umbilicus due to blood infiltration of the abdominal wall tissues (Cullen's sign).

Commentary. Pain localized in the upper quadrant of the abdomen radiating to the left hemithorax or left shoulder is Kehr's sign, which is observed in 15–75% of cases [2]. Abdominal distension (Heineke-Lejars sign) may be noted, which is pathogenetically associated with the dilation of intestinal loops in response to their irritation. Muscle guarding of the anterior abdominal wall is predominantly localized and detected in the left hypochondrium. Abdominal tenderness upon palpation is determined in the majority of patients. Percussion reveals the accumulation of fluid in the lateral gutters of the abdominal cavity. One of the signs of free fluid is the shifting of percussion dullness in the lateral gutters when the patient's position changes (Pitts-Ballance-Tomayer sign).

2.3 Laboratory Diagnostics

Commentary. Initially, there are no significant differences in the red blood cell count, Hb content, and Ht value, indicating that these parameters are not early and specific signs, which should be taken into account when choosing treatment tactics.

2.4 Instrumental Diagnostics

Commentary. The study makes it possible to detect indirect signs of closed splenic injury: high standing of the left diaphragm dome, atelectasis of the lower lobe of the left lung, and left-sided hydrothorax. In the supine position, indirect signs of splenic injury can be detected by the presence of free fluid in the abdominal cavity: widening or medial displacement of the stomach determined by the gas bubble, medial and downward displacement of the descending colon, upward displacement of the urinary bladder (blood accumulates in the pelvic cavity), floating loops of the small intestine, and indentation of the splenic flexure of the colon [3].

• To identify the type of splenic injury, it is recommended that all patients undergo a comprehensive ultrasound examination of the abdominal organs [13,14]

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Commentary. A rational examination protocol includes a comprehensive ultrasound examination of the abdominal organs immediately upon admission, at 8–12, 16–24, and 36–48 hours after the injury, followed by follow-up examinations on days 7, 14, and 21 of the illness. In the presence of appropriate clinical indications (threat of ongoing or secondary bleeding, increase in the volume of an intra-organ hematoma, two-stage trans-capsular organ rupture, infection of the contents of a "false" post-traumatic cyst, etc.), the required frequency of echographic examinations increases significantly, and the interval between them is shortened to 1–3 hours.

Experience with the use of echography in pediatric emergency surgery allows us to recommend an abdominal examination involving initial visualization of specific anatomical and topographical regions (pelvis, lateral gutters) for the diagnosis of hemoperitoneum using our previously developed method, followed by scanning of parenchymal organs. Examination of the spleen is performed (depending on the severity of the victim's condition) in the right lateral decubitus or supine position. The combination of longitudinal, oblique, and transverse scanning with changes in the transducer angle ensures reliable visualization of all segments of the spleen.

We consider it justified to distinguish direct and indirect echographic signs of various types of organ injury. Direct echographic signs include changes that directly characterize the morphological structure of the injured organ, while indirect signs include extra-organ manifestations (complications) of the trauma.

When interpreting spleen sonograms, its position, size, shape, and sharpness of contours, homogeneity of the echostructure, presence of additional (pathological) inclusions in the parenchyma, and the diameter and pulsation of the main vessels in the hilum are evaluated. A correct assessment of the identified changes involves correlating them with the time elapsed since the injury. A quantitative assessment of the acoustic density of the parenchyma is carried out using echodensitometry in a comparative aspect ("zone of interest – intact zone") and in the dynamics of the traumatic process.

Splenic contusions are accompanied by interstitial edema and hemorrhagic tissue infiltration. Direct echographic signs in the first 3–5 hours after injury are a decrease in parenchymal echogenicity and contour sharpness, as well as a "rarefied" parenchymal echostructure. Hemorrhagic infiltration of the parenchyma manifests as hyperechoic zones with blurred, indistinct contours in the injury area (Fig. 1). An increase in the size of the entire spleen or predominantly the injured segment with distortion of its configuration is characteristic. Color Doppler mapping results indicate a decrease in blood flow, the degree of which correlates with the severity of the echographic manifestations of parenchymal edema.

Fig. 1. Splenic contusion. The zone of hemorrhagic infiltration is indicated by arrows.

In the dynamics of the acute period of trauma, within 2–3 days, there is a tendency toward a decrease in the size of the organ (segment) and restoration of its configuration, normalization of parenchymal echogenicity with a simultaneous decrease in the "rarefaction" effect, and an increase in contour sharpness.

The mentioned changes are due to the regression of tissue edema, which is completed by the 5th–7th days of the post-traumatic period. At the same time, the gradual disappearance of hyperechoic zones without clear margins is observed over the course of 2–3 weeks, indicating the reduction of hemorrhagic impregnation of the parenchyma.

Subcapsular ruptures of the spleen are characterized by the extent of injury localization, the volume of blood extravasated into the traumatic cavity, and temporal parameters.

A direct and most consistent (during the acute period of trauma) echographic sign of subcapsular spleen ruptures with the formation of intraorgan hematomas is the presence of an echonegative zone within the parenchyma (Fig. 2, a, b). In hematomas localized in the region of the splenic poles or along its diaphragmatic surface, the echonegative zone has a crescent shape that follows the contour of the organ (Fig. 2, c).

Fig. 2. Echogram of a subcapsular rupture of the spleen: a – intraorgan hematoma; b – linear ruptures of the parenchyma; c – subcapsular hematoma.

Deep ruptures, including central ones, are visualized during this period as irregularly shaped echonegative zones with indistinct stellate margins. Color Doppler mapping reveals a vascular pattern defect in the area of the parenchymal injury, which indicates a disruption of the vascular angioarchitecture of the spleen.

It should be noted that during the initial examination (3–5 hours after trauma), in not a single observation was it possible to reliably detect a subcapsular spleen rupture in the form of an echonegative zone. The injuries were visualized as poorly defined areas of the parenchyma with slightly reduced echogenicity, possessing a "blurred" structure atypical for the splenic parenchyma (Fig. 3).

Fig. 3. Echogram of a subcapsular rupture of the spleen (3–5 hours after trauma). The injury zone is indicated by arrows.

Scanning of the spleen 8–12 hours after trauma reveals a progressive uneven decrease in acoustic density within the area of interest (Fig. 4, a). Reliable visualization of the echonegative zone (interstitial hematoma) becomes possible after the first 24 hours of the post-traumatic period have elapsed (Fig. 4, b).

Fig. 4. Echogram of a subcapsular rupture of the spleen: a – 8–12 hours after trauma; b – 24 hours after trauma.

In a number of cases, several closely spaced echonegative zones are detected. In practically half of the observations, echopositive fragments of various sizes and shapes, representing blood clots and tissue sequestra, are visualized within the traumatic cavity (Fig. 5, a, b). This viewpoint is confirmed by their regression with the formation of a fine-dispersed sediment suspension in the cavity contents after 7–10 days following the trauma.

Echographically, the evolution of intraorgan hematomas is characterized by a progressive reduction in the volume of the traumatic cavity, a decrease in margin definition, and a heterogeneous increase in the echogenicity of its contents due to filling with multiple punctate structures corresponding in echogenicity to the splenic parenchyma (Fig. 6).

Fig. 5. Echogram of a subcapsular rupture of the spleen: a – blood clot in the post-traumatic cavity; b – tissue sequestrum in the post-traumatic cavity.

Fig. 6. Reparative regeneration in splenic trauma. Punctate echoes in the post-traumatic cavity are indicated by arrows.

It should be noted that the shape of the traumatic cavity also undergoes certain changes, losing its characteristic stellate contour and acquiring rounded outlines. The duration of reparative and regenerative processes in subcapsular spleen ruptures is determined primarily by the size (volume) of the traumatic cavity and reaches up to 4 months, after which complete normalization of the acoustic density and echostructure of the organ parenchyma is stated. Color Doppler mapping results also indicate full recovery of blood flow.

Transcapsular ruptures of the spleen manifest as a disruption of the organ's contour continuity and the visualization of intraorgan rupture lines (Fig. 7). The latter represent a hypoechoic or echonegative zone (depending on the time elapsed since the trauma) of linear or "branching" shape with uneven and indistinct margins. It is important to note that direct echographic signs, while pathognomonic for this type of injury, are not obligatory. In particular, disruption of the splenic contour continuity is observed in only 25.4% of patients, and the intraorgan rupture line is visualized in 60.3% of cases. At the same time, the possibility of detecting these signs at early stages is highly problematic and becomes feasible only 16–24 hours after trauma.

Fig. 7. Echogram of a transcapsular rupture of the spleen. The contour disruption is indicated by an arrow.

Comparison of echographic findings with intraoperative (including endosurgical) examination data suggests that the factors determining the possibility of ultrasound visualization are primarily the size of the traumatic cavity and the presence of diastasis between its walls.

Superficial ruptures of the spleen, regardless of the intensity and duration of the resulting internal hemorrhage, are not detected echographically in the vast majority of observations.

In view of the above, indirect echographic signs of a transcapsular organ rupture acquire special clinical significance, primarily intraperitoneal hemorrhage, which was noted in all patients with this type of trauma. Perisplenic hematoma (Fig. 8) is a peri-organ blood collection completely or partially surrounding the damaged spleen and bounded by such anatomical structures as the diaphragmatic dome, the posterior leaf of the parietal peritoneum, intestinal loops, fixed omental folds, etc.

Fig. 8. Echogram of a transcapsular rupture of the spleen. The perisplenic hematoma is indicated by arrows.

The next most significant and frequently detected indirect echographic sign of a transcapsular spleen rupture is the visualization of greater omentum tissue fixed in the injury zone or enveloping the entire organ (Fig. 9).

Fig. 9. Echogram of a transcapsular rupture of the spleen. The fixed omental fold is indicated by arrows.

Fragmentation (avulsion of the pole) of the spleen is essentially a particular variant of a transcapsular rupture with complete dissociation of the organ fragments. Along with separate visualization of the fragments, rupture lines and the aforementioned indirect signs characteristic of this type of injury are detected (Fig. 10).

Fig. 10. Echogram of a complete transverse rupture of the spleen. The rupture line is indicated by arrows.

Thus, echography has high diagnostic informativeness in closed splenic injuries. At the same time, it should be borne in mind that the resolving power of the method (in detecting local post-traumatic changes in the organ structure) is not constant and is largely determined by the timing of the examination—effectively, the time elapsed since the moment of trauma.

It should be stated that in the first hours after trauma, when the fundamental issues for substantiating treatment tactics must be resolved from a clinical standpoint, the capabilities of echographically detecting intraorgan spleen ruptures appear minimal. This circumstance dictates the advisability, within the specified time frame, of relying primarily on indirect echographic signs of splenic trauma: the presence of free fluid (blood) in the abdominal cavity, perisplenic hematoma, greater omentum fixed in the area of the suspected rupture or enveloping the organ, etc.

Visualization of interstitial rupture zones and those disrupting the spleen capsule becomes possible 4–6 hours after the moment of trauma. This phenomenon is due to the evolution (lysis, clot retraction) of the blood extravasated into the traumatic cavity and the corresponding changes in its echogenicity. At earlier stages, the echogenicity of the blood clot is comparable to that of the splenic parenchyma. This circumstance may impede their acoustic differentiation, which must undoubtedly be taken into account when interpreting echograms.

The developed criteria for the differential diagnosis of various types of organ damage are of paramount tactical importance. It should be noted that the possibility of misidentifying the type of injury is particularly high when the significance of individual symptoms in the early post-injury period is absolutized. Symptom complexes that include both direct and indirect signs of the nature and localization of the injury are characterized by greater diagnostic reliability. In particular, the combination of a visualized splenic rupture line with the presence of blood in the abdominal cavity undoubtedly indicates a trans-capsular injury.

The results of dynamic echographic studies in the acute and long-term periods of splenic injuries indicate the adequacy of the method in determining the nature and completeness of reparative-regenerative processes, as well as the possibilities for timely diagnosis of various complications. Ultrasound examination in patients with closed splenic trauma represents a tripartite task, the solution of which, along with identifying the type of organ injury, involves determining the volume of blood shed into the abdominal cavity, and differentiating between stopped and ongoing bleeding.

• All patients with splenic trauma are recommended to undergo a comprehensive ultrasound examination of the abdominal organs to determine the volume of blood in the abdominal cavity [14].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comment. Depending on the time elapsed after the injury, blood in the abdominal cavity appears on ultrasound as an echonegative (in the first hours) or hypoechoic (at later stages) zone filling spaces free from internal organs. A correlation has been established between the volume of spilled blood and the echographic picture, with the conditional identification of three levels of hemoperitoneum.

Echographic visualization of fluid only in the pelvic cavity corresponds to a "small" hemoperitoneum, with a blood volume not exceeding 7.3 ml/kg of body weight (Fig. 11).

Fig. 11. "Small" hemoperitoneum: 1 – urinary bladder; 2 – blood.

In "moderate" hemoperitoneum, in addition to the pelvic cavity, blood is echographically detected in the hepatorenal pouch, lateral gutters, and perisplenic space; its volume ranges from 7.6 to 25.8 ml/kg of body weight (Fig. 12).

Fig. 12. "Moderate" hemoperitoneum: 1 – liver; 2 – kidney; 3 – blood.

The presence of fluid also beneath the anterior abdominal wall in the mesogastric region corresponds to a "large" hemoperitoneum with an intra-abdominal blood volume of more than 26.7 ml/kg of body weight (Fig. 13).

Fig. 13. "Large" hemoperitoneum: 1 – loops of the small intestine; 2 – blood.

Comment. Computed tomography of the abdominal organs (CT) is considered the "gold standard" for diagnosing splenic injuries due to its high diagnostic informativeness. It allows for "non-contact" simultaneous examination of all anatomical structures located in the plane of the transverse slice. CT shows with sufficient precision the amount of blood in the abdominal cavity and its location, as well as the presence and localization of active arterial bleeding, for example, due to a ruptured splenic artery aneurysm. CT helps identify quantitative and qualitative changes in the spleen based on the assessment of the degree of its injury.

Normally, the spleen is defined as a homogeneous organ with an absorption coefficient equal to that of the liver (35–55 HU), which increases by 20–30 HU after intravenous enhancement. Let us turn to the CT semiotics of injuries.

Splenic hematoma. On native scan computed tomography, the spleen with a hematoma is enlarged in size and deformed, predominantly in the affected area. The concavity of the contours along the medial surface disappears, and it acquires an oval shape. The texture and structure of the hematoma undergo changes depending on the time of its appearance. In the acute phase (up to 4 hours post-injury), the hematoma may be isodense, but it more often exceeds normal splenic tissue values by 5–10 HU (Fig. 14).

Fig. 14. CT signs of a splenic hematoma 4 hours after injury. Native scan. 1 – focus of fresh hemorrhage (54 ± 3 HU) in the posterior pole of the spleen.

If the "age" of the hematoma does not exceed 2 days, its density maintains values isodense to the spleen. Over the subsequent 10 days, the densitometric characteristics of the hematoma gradually decrease, becoming lower than the density of the spleen.

Subacute and chronic hematomas lasting more than one month may retain their primary shape, but due to blood clot lysis and protein resorption, they have attenuation coefficient values approaching those of water.

Post-contrast scanning is essential to use in the diagnosis of splenic trauma in the subacute and acute stages, when the hematoma is most often isodense with undamaged splenic tissue. In this case, areas without contrast enhancement, corresponding to foci of hemorrhage, are revealed in the affected zone against the background of enhanced normal pulp.

Also, if an intravenous enhancement study is performed 1–2 hours after injury, cloud-like fields of high densitometry (greater than 60 HU) may be detected within the hematoma with lower densitometric indicators, indicating ongoing bleeding.

Subcapsular hematoma. The spleen is enlarged in size and deformed, most often in the region of the poles and along the diaphragmatic surface.

On computed tomography, pathological contents are detected along the lateral edge of the spleen, most often in the form of a crescent (Fig. 15). Densitometric parameters and the structure of the contents depend on the time of appearance of the hematoma. Thickening of the convex lateral surface occurs due to the injury.

Fig. 15. CT signs of a subcapsular splenic hematoma 2 weeks after injury. Native scan. 1 – splenic tissue; 2 – hematoma.

Intraparenchymal hematoma. The spleen is enlarged in size and deformed. On computed tomography, irregularly shaped fields of pathological densitometry are determined within the pulp, which in the acute and subacute stages may be well visualized only after intravenous enhancement. At later stages of hematoma formation, this is possible without additional contrast administration. The hematoma has uneven edges and sometimes appears as "tissue fragments" (Fig. 16).

Fig. 16. CT signs of an intraparenchymal splenic hematoma 9 days after injury:

a – native scan; b – after intravenous enhancement. 1 – hematoma (28 ± 5 HU).

Splenic rupture. On computed tomography, splenic ruptures are less noticeable than subcapsular hematomas, with more diverse manifestations. The following may be detected: a defect in the splenic contours filled with pathological contents; indistinctness of the organ contours; inhomogeneity of the splenic structure; linear, stellate, or rounded fields of reduced densitometry. Splenic ruptures are usually accompanied by an intratissue hematoma, the presence of a perisplenic clot, and free fluid in the left subdiaphragmatic space or other parts of the abdominal cavity.

Splenic laceration (mashing). Using computed tomography in the left subdiaphragmatic space in the projection of the spleen, a heterogeneous mass is found, the densitometric parameters and structure of which depend on the time of its appearance. If the spleen is visualized, gross deformation of its contours and shape, the absence of normal structure, and the presence of intraparenchymal and perisplenic hematomas are characteristic.

Perisplenic hematoma. In small splenic ruptures, a perisplenic hematoma may resemble a "truncated cufflink". With large perisplenic hematomas, the spleen appears as if walled off in pathological contents, its respiratory movements are sharply reduced or completely absent, and it is seemingly impacted in the left hypochondrium. The texture and structure of the perisplenic hematoma depend on the timing of its formation and undergo changes similar to those of a splenic hematoma.

Computed tomography makes it possible to detect pathological contents around the spleen, most often along the diaphragmatic surface (in the area where the rupture is localized), the structure and texture of which depend on the time of occurrence of the hematoma. When examining the patient on their right side, it does not shift to other parts of the abdominal cavity. A large hematoma encompassing the spleen can deform the stomach and colon.

Hemoperitoneum. Computed tomography of the left subdiaphragmatic space and other abdominal compartments reveals pathological fluid whose shape conforms to the peritoneal recesses. Its configuration changes when the patient's body position is altered. Initially, the densitometric characteristics of the fluid exceed 60 Hounsfield units (HU), and it subsequently becomes hypodense.

Comment. Contraindications: diagnostic and therapeutic laparoscopy is contraindicated in patients with closed abdominal injuries presenting with severe hypotension, where blood pressure can only be maintained through continuous infusion of blood and crystalloid solutions. In this scenario, extensive internal organ injuries and hemoperitoneum with ongoing severe hemorrhage are highly likely. These patients require emergency laparotomy and hemostasis.

Endoscopic appearance of the abdominal cavity. The presentation of traumatic injuries to parenchymal organs is highly variable: ranging from small linear tears and subcapsular hematomas of various sizes to extensive maceration. Endoscopically, blood clots covering the injury are found in the area of organ rupture. This is a reliable sign that allows for precise localization of the bleeding source. It is inadvisable to remove the clots with an instrument in an attempt to determine the direction and number of tears, as these manipulations may increase bleeding. Stable fixation of the greater omentum to the injured parenchymal organ is a criterion for the completion of spontaneous hemostasis in practically 90% of cases, ensuring reliable hemorrhage arrest and an uneventful healing process.

If there is a small amount of blood in the abdominal cavity that does not increase after aspiration, and organ exploration reveals small linear tears without signs of bleeding, the patients are managed conservatively. Laparoscopy is concluded with abdominal cavity drainage. A silicone safety catheter is placed directly near the injured organ or in the pelvic region. Sometimes, exploration of the spleen reveals subcapsular hematomas. This type of injury is typical for patients who have fallen from a height. Multiple small subcapsular hematomas are harmless and do not require surgical treatment. Large solitary subcapsular hematomas are usually accompanied by severe pain and carry a risk of spontaneous rupture. In such cases, the hematoma is punctured under visual control. Bleeding from the puncture site usually does not continue. In this situation, it is also necessary to leave a safety catheter in the abdominal cavity, which can be used to induce pneumoperitoneum if repeat laparoscopy is required. Certain difficulties arise when retroperitoneal hematomas are detected in the lateral gutters. In this case, the endoscopist cannot definitively state whether there is a kidney injury or not. This can be assumed with a high degree of probability only in the case of large, tense hematomas completely occupying the entire lateral gutter. Additional diagnostic methods (comprehensive abdominal ultrasound, intravenous urography, radioisotope diagnostics) allow for a definitive and correct diagnosis. Intestinal rupture is quite difficult to visualize during laparoscopy, as it requires a thorough and methodical exploration of all intestinal loops. There are several indirect signs of intestinal wall rupture: paresis of the injured loop, pulling of the omentum toward the rupture site, and the presence of turbid effusion in the abdominal cavity. Therefore, laparoscopy must begin with a panoramic overview of the entire abdominal cavity, paying attention to the condition of the intestinal loops and the position of the omentum.

Consequently, laparoscopy in suspected abdominal organ injuries not only helps resolve the necessity of laparotomy and the choice of surgical access, but also significantly expands the possibilities of conservative management in this very challenging category of patients.

2.5 Other Procedures

None provided.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1. Conservative management

Comment. Conservative treatment implies dynamic monitoring of the patient in the intensive care unit, which includes round-the-clock blood pressure monitoring, pulse monitoring, a complete blood count including red blood cell and total hemoglobin levels, comprehensive abdominal ultrasound every 2–3 hours, and transfusion of intravenous solutions as indicated. Strict bed rest is prescribed. After 24–48 hours of non-operative management, the patient is transferred to the general surgery ward. Predictors of non-operative management for splenic trauma in children are presented in Appendix G1.

Proposals for non-operative management of pediatric splenic trauma by the World Society of Emergency Surgery [10].

- Non-operative management is the first-line treatment in hemodynamically stable patients with blunt splenic trauma;

- Patients with moderate-to-severe blunt trauma and penetrating splenic injuries should be transferred to specialized pediatric surgical centers after hemodynamic stabilization;

- Non-operative management of pediatric splenic injuries should be performed in hospitals with continuous monitoring, angiography, qualified surgeons, emergency surgical capabilities, and direct access to blood products;

- Non-operative management of children with splenic trauma should be undertaken even in the presence of concomitant traumatic brain injury;

- Organ removal should be avoided in hemodynamically stable patients with isolated splenic trauma;

- Non-operative management is contraindicated in the presence of peritonitis and bowel evisceration;

- Contrast extravasation on CT is not an indication for splenectomy;

- Pediatric intensive care unit admission for isolated splenic trauma may be required only for moderate and severe organ injury grades;

- The majority of children do not require angiography and embolization for contrast extravasation on CT or high-grade organ injury;

- Angiography and embolization may be performed for post-traumatic splenic pseudoaneurysm prior to hospital discharge;

- The risk of post-traumatic aneurysm formation in children is very low, and they resolve spontaneously;

- Following non-operative management of moderate-to-severe splenic injury, a child may return to physical activity after 6 weeks;

- Follow-up CT scans are not required before or after hospital discharge following conservative management of isolated splenic trauma.

3.2 Surgical Treatment

• In all patients with hemodynamic instability due to ongoing intra-abdominal bleeding, lack of response to fluid resuscitation, and presence of peritonitis due to associated hollow viscus injury, surgical treatment is recommended [4,10,28,29,30,33,34].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comment. The strategy of organ-sparing surgery should be adhered to as much as possible in pediatric splenic injuries. Spleen-preserving techniques involve topical hemostasis—packing of tissue lacerations or suturing using the greater omentum (omentosplenorraphy), segmental splenic resection preserving the segmental blood supply, and atypical splenic resection with preserved blood flow in the remaining tissue via collateral vessels of the splenorenal ligament. If splenectomy is performed as a forced measure, autotransplantation of splenic tissue is indicated [29].

General rules for performing surgical manipulations on the spleen

Midline laparotomy is the universal approach for abdominal organ injuries for the following reasons:

* equally good exposure during interventions in the upper and lower abdominal compartments;

* creation of conditions for adequate exploration of all abdominal and retroperitoneal regions;

* possibility of extension using one of the known variants if necessary;

* advantages for abdominal wall closure and relaparotomy during staged surgical correction;

* simplicity of rapid access in critically ill patients.

The aforementioned means that all operations for abdominal organ injuries are performed via a midline laparotomy, typically circumventing the umbilicus on the left side. If necessary, the incision can be extended into a full midline celiotomy.

In relation to splenic surgery, techniques that improve exposure are used, namely:

* gastric probe decompression, which provides a view of the left subphrenic space during emergency intervention.

* use of M.Z. Sigal retractors — highly desirable for splenic manipulations, as it significantly improves exposure.

* lateral rotation of the operating table is another way to improve inspection of the left subphrenic space.

As a first step after performing laparotomy and diagnosing intraperitoneal blood accumulation, it is advisable to collect blood for reinfusion according to standard rules. Returning the collected blood to the patient begins only after the abdominal exploration is completed. A contraindication to blood reinfusion is massive contamination with intestinal contents in combined injuries of the abdominal organs and a high level of hemolysis.

Exploration of the abdominal cavity begins in the area containing the maximum amount of blood clots or the source of ongoing bleeding. In splenic injuries, the liquid fraction of blood accumulates predominantly in the pelvic cavity. To perform a thorough exploration of the spleen, the assistant retracts the abdominal wall with a retractor at the synchondrosis of the left costal margin. The operating surgeon places their left hand into the subdiaphragmatic space and gently, without sudden movements, places the hand behind the spleen, after which the organ is carefully brought forward and to the right. The space beneath the left dome of the diaphragm is cleared of blood and clots, and one or more gauze packs are placed there. At the same time, the spleen is brought towards the surgical incision. Already at this stage, ruptures on the diaphragmatic surface of the spleen can be palpated, but the final diagnosis of the nature of the injuries is performed only under direct visual control, after gentle removal of blood clots from the organ capsule and mobilization. At this stage, parenchymal bleeding from capsular defects may resume as blood clots are mechanically removed. For temporary hemostasis, the tissue defects should be packed with gauze. If the initial abdominal exploration reveals no additional sources of hemorrhage and the patient's condition is not critical, the next objective is to mobilize the spleen for a comprehensive exploration and to decide on the method of hemostasis. The objective of splenic mobilization is to provide a complete view of the hilum, the lower pole, the renal surface, and the posterior aspects of the organ. A common mistake is inspecting only the upper sharp border, the gastric surface, the anterior pole, and the diaphragmatic surface of the spleen, as ruptures are frequently localized in the hilar region and on the posterolateral (renal) surface of the organ. Unrecognized injuries lead to incorrect management choices and, ultimately, postoperative hemorrhage. Mobilization of the spleen by dividing its ligaments is performed "from right to left." To do this, the assistant retracts the splenic flexure of the colon to the right and downward, and uses a retractor to push the left lobe of the liver to the right and upward, exposing the left subdiaphragmatic space. The left part of the gastrocolic ligament is divided between clamps. Its lateral section is also called the splenocolic ligament, where the left gastroepiploic artery (*a. gastroepiploica sinistra*) originates from the splenic artery or its segmental branches, which must be kept in mind during mobilization. After accessing the lesser sac, it is possible to examine the main vessels of the spleen and the hilar region, the projection of which is often infiltrated with blood (especially in blunt trauma). The next stage of exploration is the division of the gastrosplenic ligament. To do this, the surgeon inserts the fingers of the left hand into the lesser sac, puts tension on the gastrosplenic ligament, and divides it stepwise between applied clamps. This divides the short gastric vessels — branches of the splenic artery; therefore, the tissues beneath the clamps must be carefully ligated both near the greater curvature of the stomach and at the splenic hilum. Near the posterior pole, the gastrosplenic ligament often becomes narrow — the distance between the greater curvature and the splenic hilum is 0.5-1 cm, so the mobilization of the upper parts of this ligament must be performed with caution. Since any interventions on the spleen conclude with drainage of the left subdiaphragmatic space, and often with the placement of a hemostatic pack, the left colic flexure should be lowered as the reversible exploration phase of the spleen is completed. To do this, the phrenicocolic ligament (Payr's membrane) is divided. Before deciding on the nature of the intervention on the spleen, one should avoid dividing the deep layer of the phrenicosplenic ligament (splenorenal ligament) if possible, since one of the options for splenic resection involves preserving it as a source of collateral blood supply to the stump. After mobilization, the most important structures become readily accessible for inspection: the splenic hilum, the tail of the pancreas, and the main splenic vessels, making it possible to adequately assess the injuries (or the localization of the pathological process) and determine further management.

The described sequence of actions is applicable when there is no massive ongoing hemorrhage from the spleen or other sources. There are situations requiring forced actions when the algorithm may be modified:

* intensive hemorrhage from the main and/or segmental vessels of the spleen;

* multiple sources of hemorrhage in the abdominal cavity;

* initial manifestations of decompensated shock;

* severe extra-abdominal associated injuries.

In such cases, temporary hemostasis techniques are indicated, which can be simple and less traumatic, or complex.

Methods of local hemostasis

For this purpose, packing with a hemostatic tampon is used. Tamponade of a splenic rupture is the simplest yet reliable way to complete the operation for capsular ruptures and superficial parenchymal defects; it is indicated when bleeding has stopped by the time of surgery, when the removal of clots from the surface of the capsule has not led to the resumption of hemorrhage, or when parenchymal bleeding has been effectively stopped by thermocoagulation methods. It is a well-known fact that capillary bleeding in superficial splenic injuries stops upon mechanical compression with a gauze pack with an exposure time coinciding with the duration of abdominal organ exploration and peritoneal toilet (removal of liquid blood and clots, sanitation of the abdominal cavity with solutions). The gauze pack should be positioned near the spleen in such a way as to create a pressure vector toward the damaged area, but using this as a definitive hemostatic method is only possible with a distinct cessation of capillary bleeding. The fact is that the use of a tampon does not guarantee the cessation of bleeding, but serves only as a means of preventing further hemorrhage. For its correct placement, it is necessary to retract the left colic flexure to the right and downwards, and if necessary, mobilize the descending colon fixed in the left paracolic gutter (achieved by incising the peritoneum laterally from the colon until the pre-renal fascia is exposed). In the left lumbar-lateral region, a skin incision is made, perpendicular to the long axis of the body, up to 5 cm in length. The aponeurosis of the external oblique abdominal muscle is incised, and a channel is formed down to the parietal peritoneum, which must be incised at the most dependent site. After mobilizing the left half of the colon, the projection of the counter-incision is such that the tampon is placed on the pre-renal fascia. The assistant uses Farabeuf retractors to spread the tissues, facilitating access.

To prevent contact of the gauze with the intestinal wall and to improve drainage from the peritoneal cavity, we thread the prepared tampon into a surgical glove with cut-off fingers (glove-gauze composition) resembling a Penrose drain. Before placing the tampon, a drain is placed in the left subphrenic space, with its last opening located near the parietal peritoneum incision to prevent fluid accumulation in the left paracolic gutter. Then, the spleen is returned to its bed, avoiding kinking of the pedicle; the tampon is tightly fixed over the damaged capsule and placed in the left paracolic gutter, lateral to the splenic flexure and the descending colon.

Segmental angiodeduction

This term refers to the ligation of damaged segmental vessels while preserving an intact spleen — an uncommon method of stopping bleeding. It is used for isolated injury of the anterior pole of the spleen, when hemorrhage is caused by the avulsion of the anterior polar artery.

In foreign literature, angiodeduction refers to a technique that involves ligating the main trunk of the splenic artery to achieve hemostasis in massive ruptures of the organ parenchyma. Necrosis is avoided due to blood supply via the short gastric vessels, accessory polar vessels, and pancreatic branches of the splenic artery. The surgical technique involves suturing the anterior part of the splenic hilum, through which the damaged polar vessel passes.

Omentosplenorrhaphy

Splenorrhaphy — the suturing of a splenic wound — is a traditional, fairly simple to perform, and reliable method of stopping bleeding from a splenic wound. The use of the greater omentum as a plastic material when placing the suture (omentoplasty) significantly increases the reliability and effectiveness of the suture.

Two variants of omentoplasty are known: with a preserved blood supply (pedicled) and using an isolated omentum. Preference should be given to a pedicled omentum, assuming that preserving blood supply has a positive effect on its hemostatic properties and the course of the local wound healing process.

Indications: single ruptures of the splenic tissue on the diaphragmatic surface and in the polar regions of the spleen.

Three strips are fashioned from the greater omentum, their size chosen depending on the size and location of the splenic wound. The two outer strips are placed along the edges of the splenic wound. Then, interrupted catgut sutures are applied, passing the threads through the omental strip located on one edge of the wound, the capsule and pulp of the spleen beneath the bottom of the wound, and out to the other edge of the rupture through the capsule and the omental strip located on it. After placing all the sutures, the middle strip of the greater omentum is placed into the wound and the threads are tied, carefully tightening them until hemorrhage ceases. Thus, the omental fragments placed at the edges of the spleen serve as cushioning pads, preventing the thread from cutting through the splenic tissue, while the middle strip acts as a biological tampon. When the depth of the splenic wound is 0.5–1.0 cm, splenorrhaphy is performed with omentoplasty using a single omental strip. For this, a part of the greater omentum with preserved blood supply is fashioned so that the omental tissue completely fills the splenic wound and lies freely on its edges, protruding by approximately 1.5 cm. Then, interrupted sutures are applied at a distance of about 1.0 cm from one another, passing the ligature through the omentum located on one edge of the wound, the capsule and pulp of the spleen beneath the bottom of the wound to the other side, and further through the capsule and the part of the omentum located on the opposite edge of the wound. The ligatures are tied with a surgical knot and tightened, preventing capsular tearing.

Segmental resection of the spleen

Resection techniques have significantly expanded the possibilities of organ-preserving surgeries in organ trauma.

Indications for splenic resection:

1) deep ruptures of the splenic pulp when splenorrhaphy is impossible or ineffective;

2) injuries extending to the splenic hilum with active bleeding;

3) two-stage splenic ruptures with extensive capsular detachment and secondary parenchymal bleeding, when a part of the organ is preserved.

Conditions for performing a splenic resection:

* preservation of a part of the organ with main blood flow;

* integrity of the capsule of the remaining part;

* stable blood pressure readings during the operation.

Fundamentally, splenic resection includes the stages of organ mobilization, ligation of the vessels of the resected part, excision of the damaged tissue, and hemostasis from the cut surface of the organ. The final stage is the most critical, since the main danger of splenic resection — recurrent postoperative bleeding — can negate all efforts aimed at preserving a part of the organ.

A method of spleen resection in which hemostasis is achieved by tightening a circular ligature placed around the spleen at a distance of 0.7–1.0 cm from the intended line of organ transection, after which the damaged area is removed and the cut surface is peritonized with a greater omentum flap. The sutures used to fix the greater omentum tissue to the plane of the spleen transection are passed behind the compressing circular ligature. The use of a circular ligature significantly simplifies the cessation of arterial and parenchymal bleeding after transection of the organ in the chosen plane. This eliminates the need to perform resection along the hypovascular zone, which makes it possible to preserve more blood-supplied spleen tissue than with classical segmental resection. The key to performing this procedure is creating sufficient compression to stop blood circulation in the trabecular and segmental vessels entering the transection plane while avoiding damage to the splenic capsule. To create uniform pressure on the splenic tissue and ensure convenience in fixing the omental flap to the cut surface, modifications of the method have been proposed that involve placing two ligatures around the organ instead of one, which are tightened alternately. If bleeding vessels are still present on the cut surface within the transection plane, targeted suturing directly on the cut surface is sufficient to stop the bleeding.

Atypical (planar) spleen resection

Atypical spleen resection refers to the excision of a part of the organ without taking its segmental structure into account. The method presented here is more accurately termed subtotal atypical spleen resection with interruption of the main blood supply. According to the surgical technique, it is referred to as a "planar" spleen resection, since the section is made in the oblique-sagittal plane, and the formed stump is connected throughout its entire length to the splenorenal ligament, which serves as a new "vascular pedicle" (the "mesentery" of the splenic stump, analogous to the blood supply of the small intestine). The pathophysiological rationale for the developed intervention is the preservation of a certain amount of splenic tissue with preserved (albeit reduced) blood supply, aimed at preventing post-splenectomy hyposplenism in the early postoperative period and subsequent organ regeneration.

Indications for atypical spleen resection: grade III–IV spleen injuries with an unchanged area of the capsule and pulp maintaining a connection with the splenophrenic ligament, provided the patient is in a stable condition during surgery.

In addition to the described methods of local hemostasis, the following methods are also possible.

The application of absorbable hemostatic materials, such as collagen adhesive, activated microcrystalline collagen, or biogenic tissue adhesives, can help control bleeding in superficial capsular injuries. Fibrin glue, which is a biological hemostatic agent, is also used.

Autosplenic transplantation

Autotransplantation of splenic tissue is one of the methods for preventing post-splenectomy disorders through the replacement of certain splenic functions. The transplantation of splenic tissue is based on the known phenomenon of its engraftment with the formation of structures characteristic of the red pulp of the spleen with elements of the white pulp.

The following options for splenic tissue transplantation have been proposed:

1. According to the method of tissue preparation:

1.1. Homogenization

1.2. Fragmentation (tissue cubes)

1.3. Tissue strips (tangential sections of the organ)

1.4. Isolation of splenic subsegments

2. According to the autotransplantation site

2.1. Into the greater omentum with creation of a double-layered free edge or by carving and wrapping an omental flap

2.2. Into the omental bursa

2.3. Into the mesentery of the small or large intestine

2.4. Into the retroperitoneal space (including with omentoplasty)

2.5. Into the posterior abdominal wall (including with omentoplasty)

2.6. Into the anterior abdominal wall (onto the posterior leaflet of the rectus abdominis sheath)

2.7. Into the subcutaneous adipose tissue

3. According to the nature of medical processing

3.1. With preliminary processing (pulp perfusion, anti-ischemic treatment, antibacterial treatment)

3.2. Without processing

4. According to the timing of autotransplantation

4.1. Intraoperative

4.2. Delayed (in the early postoperative period)

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• All patients who have undergone splenectomy are recommended vaccination and long-term antibiotic therapy (with systemic antibacterial drugs) to prevent hyposplenic infectious complications [10,29,30,31,35].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

Commentary. Splenectomy leads to immunoglobulin imbalance, a drop in the concentration of specific antibodies, reduced bacterial opsonization, and a decrease in complement component levels [10,29,30]. The most dangerous complication after spleen removal is overwhelming post-splenectomy infection (OPSI) and post-splenectomy sepsis. The mechanisms of development of post-splenectomy sepsis are associated with a deficiency of antibodies against the pathogen's capsular polysaccharides, most commonly Streptococcus pneumoniae (23 serotypes identified in 85% of fulminant infection cases), Neisseria meningitidis (groups A, C, Y, W135), and Haemophilus influenzae type B in children [10,29,30]. The purpose of vaccination is to induce an immune response against the capsular components of the pathogens.

Prophylactic antibiotic therapy is administered for life to high-risk patients, particularly children under 6 years of age, as well as those with an inadequate serological response to the pneumococcal vaccine and a history of pneumococcal disease [35].

5. Prevention and Dispensary Observation

• All children with a removed spleen are indicated for the prevention of post-splenectomy infection [10,29,30]:

- Conducting educational programs for asplenic patients, pediatricians, and general practitioners on the early diagnosis of infectious diseases;

- Informing patients about potential lifelong complications due to increased susceptibility to severe infectious diseases;

- Warning dentists and paramedical specialists about potential risks of their interventions.

6. Organization of Medical Care

Indications for hospital admission to a medical organization:

1) Anamnestic and clinical data indicating spleen injury.

Indications for discharging a patient from a medical organization:

1) Stable hemodynamic parameters.

2) Normalization of laboratory data, including hematocrit and hemoglobin values.

3) Full enteral feeding.

4) Absence of abdominal pain syndrome and anterior abdominal wall muscle guarding.

7. Additional Information

No.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Apartsin K.A. – Doctor of Medical Sciences, Professor. Russian Society of Surgeons.

2. Belyaeva O.A. – Candidate of Medical Sciences. Russian Association of Ultrasound Diagnostics in Medicine.

3. Grigoriev E.G. – Doctor of Medical Sciences, Professor, Corresponding Member of the RAS. Russian Society of Surgeons.

4. Karaseva O.V. – Doctor of Medical Sciences, Professor. Russian Association of Pediatric Surgeons.

5. Komissarov I.A. – Doctor of Medical Sciences, Professor. Russian Association of Pediatric Surgeons.

6. Morozov D.A. – Doctor of Medical Sciences, Professor. Russian Association of Pediatric Surgeons.

7. Pikalo I.A. – Doctor of Medical Sciences. Russian Association of Pediatric Surgeons.

8. Podkamenev A.V. – Doctor of Medical Sciences, Associate Professor. Russian Association of Pediatric Surgeons.

9. Podkamenev V.V. – Doctor of Medical Sciences, Professor. Russian Association of Pediatric Surgeons.

10. Razumovsky A.Y. – Doctor of Medical Sciences, Professor, Corresponding Member of the RAS. Russian Association of Pediatric Surgeons.

11. Rozinov V.M. – Doctor of Medical Sciences, Professor. Russian Association of Pediatric Surgeons.

12. Svarich V.G. – Doctor of Medical Sciences, Professor. Russian Association of Pediatric Surgeons.

13. Shanturov V.A. – Doctor of Medical Sciences, Professor. Russian Society of Surgeons.

14. Tsap N.A. – Doctor of Medical Sciences, Professor. Russian Association of Pediatric Surgeons.

Conflict of interest: none.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of the clinical guidelines:

Pediatric surgeons

Clinical residents - pediatric surgeons

Evidence gathering methodology:

Methods used for evidence collection/selection:

Search for publications in specialized peer-reviewed periodicals with an impact factor > 0.3;

Electronic database search:

Databases used for evidence collection/selection:

The evidence base for the recommendations includes publications from the Cochrane Library, PUBMED, and MEDLINE databases. The search depth was 10 years.

Methods used for evidence analysis:

reviews of published meta-analyses;

systematic reviews with evidence tables.

Methods used for assessing the quality and strength of evidence:

expert consensus;

evaluation of the significance of evidence in accordance with the evidence rating scheme (Tab. 1-2).

These clinical guidelines present the levels of certainty of evidence for recommendations in accordance with the draft methodological guidelines for assessing the certainty of evidence and the strength of recommendations of the Center for Expertise and Quality of Medical Care of the Russian Ministry of Health.

In accordance with this draft of recommendations, certain generally accepted diagnostic methods are assigned the level GPP (Good Practice Point) based on expert consensus.

Methodology for validation of guidelines

Methods for guideline validation:

External peer review;

Internal expert review.

Description of the guideline validation methodology

The recommendations have been discussed and approved by leading specialists of specialized Federal Centers of Russia and practicing physicians.

Procedure for updating clinical guidelines

Updating is carried out at least once every three years or earlier, taking into account new information on the diagnosis and management of patients suffering from hypersplenism. The decision to update is made by the Russian Ministry of Health based on proposals submitted by medical professional non-profit organizations. The submitted proposals must take into account the results of a comprehensive evaluation of surgical methods, medical devices, and the results of clinical approbation.

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)

Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitation interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1

Related Documents

These clinical guidelines were developed taking into account the following regulatory and legal documents:

• Order of the Ministry of Health of the Russian Federation No. 562n dated October 31, 2012 "On approval of the Procedure for the provision of medical care in the profile of 'pediatric surgery'".

• Order of the Ministry of Health of the Russian Federation dated May 10, 2017, No. 203n "On approval of criteria for assessing the quality of medical care".

Appendix A3.2

Predictors of non-operative management of splenic injury in children: age, mechanism of injury, isolated and concomitant splenic injuries, grade of organ injury, time of admission to the hospital, volume of hemoperitoneum, hemodynamic status.

Age. Childhood can be considered as a favorable prognostic factor for non-operative management of splenic injuries. Analysis of clinical and epidemiological data over 50 years shows that the average age of children undergoing non-operative management is 6–10 years [21].

While the failure rate of non-operative management of splenic trauma in children is less than 5%, in adult patients it reaches 15% [22]. Non-operative management of splenic trauma in children is more effective than in adults due to differences in physiological responses to injury. The rate of unsuccessful conservative treatment of splenic trauma in adults correlates with age, which is explained by significant differences in the morphology of splenic vessels, the structure of its capsule, and the contractile capacity of splenic vessels for spontaneous hemostasis (4).

Mechanism of injury. Non-operative management of splenic trauma in children is successful regardless of the mechanism of injury. Even in cases of motor vehicle accidents, which belong to the most severe mechanisms of injury and account for up to 91%, non-operative management is successful in 98% of children [23].

Concomitant injuries and injury severity. Isolated splenic injuries in children are not associated with severe injury severity. Thus, the Pediatric Trauma Score (PTS) is 11.7 ± 0.5 for isolated and 9.6 ± 1.7 for concomitant trauma. Trauma is considered severe at a score of 8 and below. Concomitant splenic injuries are not a contraindication for non-operative management. The difference between patients with isolated and concomitant splenic trauma lies in the length of hospital stay (6.9 ± 9.0 days vs. 2.0 ± 1.2 days; p < 0.001). The need for blood transfusion in children with concomitant trauma occurs in 30.8% of cases compared to 10.8% for isolated splenic trauma. Admission to the ICU was required for 30.8% of children with concomitant trauma and only 17.7% (p = 0.09) with isolated splenic trauma [24].

Grade of splenic injury. Experience in successful non-operative management of 72 children with grade IV and V liver (n = 30) and spleen (n = 42) injuries is presented, of which 43% (n = 31) had concomitant injuries. Only 1 (2.4%) patient with grade IV splenic trauma experienced a complication due to left-sided pleurisy. In 17.9% (n = 5) of children with liver trauma and non-operative management, complications developed in the form of biloma [25].

Time from hospital admission to surgical treatment. The decision to choose conservative treatment must be made within the first 4–6 hours from the moment of the patient's admission to the clinic. During this period, the hemodynamic status, the need for infusion therapy, and the presence of concomitant injuries are determined. Literature data confirm these timeframes, noting the absence of patients requiring laparotomy after 6 hours from hospital admission [4,26].

Hemoperitoneum. The most accurate predictor for choosing the method of treatment for splenic trauma is the volume of hemoperitoneum, which is associated with the severity of blood loss and the patient's hemodynamic status.

When analyzing forensic medical examination reports of 105 children with polytrauma and concomitant splenic injury (n = 33), it was established that in victims aged 15.5 ± 1.9 years, the volume of hemoperitoneum was 255.8 ± 179.1 ml, which corresponded to blood loss of approximately 7.4 ± 6.6% of circulating blood volume (CBV). Only one child aged 8 years experienced avulsion of the spleen from the vessels, and the volume of hemoperitoneum was 1000 ml, with blood loss exceeding 50% of CBV. In 92.8% of victims, intra-abdominal hemorrhage did not exceed 15% of CBV, and only in 7.2% did it correspond to blood loss equal to 26–28% of CBV. Consequently, concomitant splenic injuries in fatal polytrauma are not associated with massive intra-abdominal hemorrhage and do not threaten the development of severe hemorrhagic shock, except for rare cases of splenic avulsion from vessels, when children die at the scene [20].

The volumes of hemoperitoneum, according to ultrasound data, in children (n = 69) with successful non-operative management of splenic trauma are presented in Fig. 17 [20].

Fig. 17. Dependence of the volume of hemoperitoneum (according to ultrasound data) on the age of children with conservative treatment of splenic trauma.

In accordance with the age norm of body weight and CBV for each group, it was found that blood loss in children under 5 years old and from 5 to 7 years old was approximately less than 15% of CBV, from 8 to 10 years old, from 11 to 13 years old, and from 14 to 17 years old – less than 10% of CBV.

The indicated volumes of hemoperitoneum can be considered completely safe for non-operative management.

It was established that in 87.5% of children with non-operative management of splenic trauma, the volume of hemoperitoneum did not exceed 500 ml and in only 12.5% ranged from 500 to 700 ml. At the same time, the maximum blood loss was 27% of CBV.

Thus, a clinically significant pattern of splenic injury in children is the absence of massive intra-abdominal hemorrhage equivalent to severe hemorrhagic shock. The presence of blood in the abdominal cavity during splenic injury is not a reliable prognostic factor for determining treatment strategy.

Hemodynamic status. Hemodynamic status corresponds to the volume of blood loss. To determine the severity of hypovolemic shock depending on the volume of blood loss, it is advisable to use the 4-stage Advanced Trauma Life Support Classification of Shock [3].

- Grade 1: loss of 15% of circulating blood volume (CBV) or less has no clinical signs of blood loss, blood pressure is normal, no microcirculatory disturbances at the capillary level. Heart rate may increase by 10-20%.

- Grade 2: loss of 20-25% of CBV, where the main clinical manifestation is orthostatic hypotension — a decrease in systolic blood pressure by 10-15 mm Hg. Tachycardia up to 150 bpm. Tachypnea up to 35-40 breaths per minute. Diuresis greater than 1 ml/kg/hour.

- Grade 3: loss of 30-35% of CBV corresponds to moderate or compensated shock: cold extremities, delayed capillary refill time ("blanching" sign), heart rate of 150 bpm or more, arterial hypotension in the supine position. Drop in systolic blood pressure below 100 mm Hg. Diuresis less than 1 ml/kg/hour. Increase in age-adjusted shock index values.

- Grade 4: loss of more than 40% of CBV corresponds to severe or decompensated shock: cold extremities, severe pallor, skin mottling, impaired consciousness up to coma, absent pulse, drop in blood pressure.

Non-operative management of splenic injuries is feasible and safe in grade 1-2 shock, and in grade 3 shock with a positive response to infusion therapy, which is manifested by a decrease in heart rate, increase in blood pressure, improvement in skin color, normalization of diuresis, and improved shock index values.

The American College of Surgeons Committee on Trauma Advanced Trauma Life Support (ATLS) protocol recommends infusion of Ringer's solution in a volume of up to 40 ml/kg and whole blood at 20 ml/kg. This method of hemodynamic stabilization is currently considered standard practice and is performed in all children with splenic injury complicated by intra-abdominal hemorrhage and hypotension [5,10,27,28].

Appendix B. Physician Action Algorithms

Figure. Splenic injury

Appendix C. Patient Information

Parents are well aware of the most common types of injuries in children, such as abrasions, scratches, contusions, and sprains, which are not life-threatening. Less common, but potentially more dangerous, are abdominal organ injuries when a child encounters high-energy external forces. This type of injury is associated with motor vehicle accidents, bicycle or motorcycle riding, falls from a height, or contact sports. Abdominal trauma can be accompanied by rapid blood loss, requiring early diagnosis and transportation to a specialized diagnostic and treatment unit. Parents should be aware that a child with abdominal trauma may exhibit the following signs: abdominal pain, increased abdominal tenderness upon palpation, rigidity of the anterior abdominal wall, pain radiating to the left or right shoulder, blood in the urine, nausea and vomiting, rapid pulse, and decreased blood pressure. The most dangerous signs are a rapid pulse and a drop in blood pressure, which indicate intra-abdominal bleeding and require emergency hospitalization of the child in a surgical inpatient department. If hemodynamic parameters do not stabilize after blood product and fluid transfusion, surgical treatment is indicated. If blood pressure and pulse remain stable, the patient undergoes ultrasound and CT scans of the abdominal organs, the results of which will determine the further treatment strategy for the child.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.